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Maps, plates, charts, etc., may be filmed at different reduction ratioa. Those too large to be entirely included in one exposure are filmed beginning in the upper left hand corner, left to right and top to bottom, aa many framea aa required. The following diagrams illustrate the method: Lea cartas, planchaa, tableaux, etc., peuvent Atre filmte i dea taux de reduction diffirents. Lorsque le document est trop grand pour htn reproduit en un seui clichi. il est filmi A partir da I'angle sup4rieur gauche, de gauche k droite, et de haut 9n bas. en prenant le nombre d'imeges iiicessalre. Lea diagrammes suivants illustrant la mithode. .,;,.. t -; : ^ 3 ■ - ■ t t » 4 5 d ^ lihu^^ C^ /< RBPRTNTED PROM THE " MONTREAL BfBDICAL JOUBlfAL." DEC. 1889. T, JOHITSOIJ-ALLOWAY, 1869. ' .^- if*; j;^*-^-v- se;^Ti':v» ".^E^SE' z- ■,.t-"'> r ■^<'i •itfi CURETTING THE UTERUS, AND THE METHODS OF T TREATING THE CAVITY AFTERWARDS. By T. Johnson-Allowat, M.D., /*^G 'sD Instructor in GynsBOoIog^, MaGill University ; Assistant Surgeon to the Montreal General Hospital ; Qynseoologist to the Montreal JMspenaary. IH Since specialists no longer regard curetting the uterine cavity with apprehension, when performed hy an experienced operator, and under properly chosen circumstances, it is interesting to study the best n^thodsof treating or dressing the wounded surface thus deprived of its endometrium. Included under this subject matter I place those cases of uterine disease which require the use of the sharp curette for the relief of ab- normal haemorrhages in all their protean forms, a- in abortion cases where much manipulation has been necessitaw i, and the uterine contents have been removed with the curette and uterine forceps. Before entering directly upon the subject it will be necessary to say a few words regarding the cases which generally require curetting, and the best kind of instrument to use. Menorrhagia and metrorrhagia indicate local disease or change in the lining membrane of the uterine cavity. In certain zymotic diseases, when we have blood change, increased men. struation is not at all uncommon. This increase in the flow is due to increased stimulation of the sexual organs under the in- fluence of these blood changes, and I have no doubt is often determined and made more pronounced by some pre-existing local disease of the endometrium. Also such conditions as in- sufficiency of the cardiac valves or emphysema will cause an increase of flow in another and diflPerent way. Metrostaxis under such circumstances does not come within the range of our subject and only requires a passing notice. If, however, a men- orrhagia should continue after the febrile attack has passed away, and in fact seem to date from it, the conditlofi should be recog- nised as one for local treatment. This is self-evident because we know that vitiated conditions of the blood and disturbances in the circulation seldom or never cause prolonged menorrhagia except when associated with an already diseased local condition. The history of a patient will often point to a statement made to the efiect that her menorrhagia began with some illness, and has continued more or less ever since. In such a case we have un- doubtedly a local disease which only wanted the opportunity to set going an abnormal function in the organ involved. Coming now to the local conditions which cause menorrhagia and metrorrhagia we may classify them as follows : — Those in- volving disease of the adn<vision many times myself, but must admit that there have been few occasions upon which I did not feel a regret that I had so acted. The operation is never so perfectly done, it is hurriedly done, and to say that the patient does not suffer pain is untrue- I have known them to suffer severely and the operation to be fol- lowed by a certain amount of shock. It is also unsafe to curette a uterus without first freely using the powerful steel dilators to at least 1 inch. This is done to ensure good drainage, and should be done whether the cervical oanal seems sufficiently patent or not. The curetting should be continued until no more endometrium can be obtained, two to three minutes being ample in point of time. The cavity should now be irrigated with plain warm water, after which we must decide what form of dressing we are going to apply. The simplest form is to let the part alone and return the patient to bed ; injection of iodized phenol, by means of a syringe made for the purpose, and containing 30 to 60 m. of the fluid. Churchill's tincture of iodine is some- times used but it is much more painful and less effective than the iodized-phenol. Swabbing the cavity with pure carbolic acid is a very good method and has in my hands given good results. Packing the cavity with pledgets of cotton wool impregnated with iodoform is the method known as VuUiets'. It is, however, diflScult to do, is clumsy, and if the cavity is packed too firmly, the procedure will give rise to severe uterine colic - Of all the methods, however, of dressing the uterine cavity after curetting, which has proved most satisfactory, is that of filling it carefully with iodoform gauze, and leaving the end extruding from the external os. The pressure here exerted upon the uterine walls can be so beautifully and perfectly graded according to the judgment of the operator, that all haemor- rhage is at once arrested. Tags of unfinished shavings are com- pressed firmly against the denuded surface, and unite there. Under other circumstances these ujQjfiniahed scrapings often 6 necrose, and the base of the shaving forms a little eddy for retention of discharges to decompose and set up trouble. The principal locality in which these spots of danger occur is just above the internal os. When iodized phenol or other cautery is applied, these jagged points are converted into little ulcerating pits from which septic absorption takes place, culminating in a sharp attack of pelvic inflammation. Every gynaecologist has experienced such unpleasant results after curetting when there previously existed no legitimate foundation for such a sequence, and may be accounted for in the manner I have described. This danger will always exist with the injection of fluid or the appli- cation of caustics to the interior of the uterus, and should not therefore be made a routine practice. Now that we are cognizant of these dangers, we can see the great safety and therapeutic advantage of filling tightly the uter- ine cavity with a soft elastic and aseptic material prepared with iodoform suspended in parafin. This material, prepared by Dyer of Montreal, is in advance of every other for this purpose. It can be left in for four or five days, if necessary, wifhout the least fear of having it undergo change. There is absolutely no drain so good, and by its side pressure on the uterine walls all remnants of undetached membrane re-unite, resulting in a per- fectly smooth cavity surface. The cases which are generally met with in which this dressing is applicable are : — Curetting for haemorrhagic endometritis ; with Schroeder's trachelorrhaphy; in bleeding myomata ; for removal of retained products after abortion, the method is especially satisfactory here. It arrests all bleeding at once, secures good drainage and induces con- traction of the uterus, thus favoring rapid involution. In a case of this nature I saw recently in consultation with Dr. Gurd, I removed a large adherent placental mass.Pregnancy had ceased at about the fifth month,but the placenta continued to grow for some time afterwards. It was so firmly adherent that it became necessary to remove it in very small fragments with curette and forceps. I packed this uterus to a fair degree of pressure, and on the second day I found the gauze had all been expelled and the uterus reduced in size with firm contraction. The gauze packing is often expelled, especially in abortion cases, but it can easily be removed on the third or fourth day by simply intro- ducing the dressing forceps to the cervix along two fingers of left hand as a guide and gently withdraring the gauze. No irrigations are required after its withdrawal as the vagina is still aseptic and will remain so if not interfered with. A word in conclusion in regard to the use of the sharp cure tie. This instrument has been held in great awe for many years by a large section of practising physicians ; and these gentlemen have always urged the use of Thomas' dull wire curette when an oper- ation of this nature was about to be performed. This general professional imprepsion having prevailed it seems apparent that there must have been some good cause for this strange aversion to the instrument. Those who have had experience with it, and have necessarily become skilled in its use will see that the cause of the above impression rests with t'vo facts — first, care- lessness or neglect in making the field of operation absolutely aseptic ; second, unskillful use of the instrument due to want of constant experience. When we consider the important meaning of these facts, it is surprising the little harm the instrument has done. /^